CT Chest

Indications: Congenital lesions : Chest truama : Inflammatory : Neoplastic : Miscellaneous : Cystic lung,.. to assess injuries to the lung, vascular structures, chest wall, bronchial tree,... lesions in the lung, mediastinum, pleura, chest wall,... primary and secondary tumours of the thorax Staging of primary extrathoracic malignancies,... diffuse lung diseases (interstitial, alveolar,..) vascular lesions (aortic aneurysm, aortic dissection, pulmonary embolism,...) Evaluation of bronchiectasis

Verification of an opacity seen on the straight chest X ray

Patient preparation: Fasting 4-6 hours before examination (most of the patients are usually injected with contrast material for adequate delination of the intrathoracic vascular structures 3 - 4 ampoules (20 ml.) water soluble contrast material (urographin,..) are injected IV before start the examination Contrast is not usually needed in these condictions: - Evaluation of bronchiectasis - Evaluation of diffuse pulmonary parenchymal disease - Searching for pul. Parenchymal deposits Patients position: Supine Scanogram: Frontal (should include the lower neck and upper abdomen) Sections: Icm section from the lung apex to the end of the costophrenic necesses Mediastinal window and lung window for all images Bone window for sections showing lesions affecting bones (ribs, spine,..) Scanning parameters - Standard routine CT chest - High resolution CT [HRCT] using special scanning parameters and filters to get a more detailed image of the lung paranchyma.. usually needed for assessment of diffuse paranchymal lung diseases and bronchiectasis - Helical CT= spiral CT (volumetric CT) Allows scanning of the whole thorax in a single breath hold Advantages: - Rapid examination technique suitable for children and uncooperative patients Ensures adequate vascular opacification with relatively less volume of contrast material injected - Avoid respiratory misregestration Anatomy The aortic arch is a fixed landmark .. at this level we identify the SVC, trachea and oesphagus. The space between the sternum and aortic arch represents the anatomic site of the thymus which is normally seen up to the age of 2 years. Sections above the level of the aortic arch show the major aortic branches (letf subclavian, left common carotid, innominate arteries) as well as both innominate veins + trachea and oesphagus. Sections below the aortic arch show the ascending and descending aorta with the pulmonary artery in between. The SVC is seen postrolateral to the ascending aorta. Lower down sections will show different cardiac chambers, descending aorta and oesphagus.

Anatomic sites of intrathoracic lymph nodes: NB Normal lymph nodes are not usually seen in CT scan (minor exceptions) Internal mammary lymph nodes along the postro lateral aspect of the sterum on both sides. Retrocaval (Rt paratracheal) lymph nodes posterior to the SVC Pre vascular (retrosternal) lymph nodes along the antrolateral aspect of the aortic arch. Aortic window lymph nodes between the ascending and descending aorta above the pulmonary artery. Carinal lymph nodes around the tracheal bifurcation Hilar (broncho - pulmonary) lymph nodes at the left and Rt hilar regions. Circum cardiac lymph nodes around the peri cardiam Poaterior mediastinal (Zygo oesphageal) lymph nodes

1 Anterior segment upper lobe 2 Apical segment upper lobe 3 Posterior segment upper lobe 2+3 Apico posterior segment of the left upper lobe 4 Apical segment lower lobe 5 Medial segment middle lobe

6 Lateral segment middle lobe 7 Inferior segment lingula 8 Superior segment lingula 9 Anterior segment lower lobe 10 Lateral segment lower lobe 11 Posterior segment lower lobe 12 Medial segment Rt lower lobe

Segmental anatomy The 1st two sections in the CT scan of the chest pass through the apex of each lung (apical segment of the upper lobe on the Rt side/apico posterior segment of the left upper lobe). The apical and posterior segments of the upper lobe on the left side form a single segment known as the apico posterior segment. Two segments in the middle lobe (lateral and medial) Two segments in the lingula (superior and inferior) No medial segment in the lower lobe on the left side The anatomic land mark for segmental distribution isthe tracheal bifurcation. Sections above the level of tracheal bifurcation (upper sections) Sections at the tracheal bifurcation (middle sections) Sections belwo the tracheal bifurcation (lower sections)

DIAGNOSIS OF PULMONARY LESIONS

Focal pathology Nodules Masses Patches Cavities Pulmonary nodules A rounded well defined pulmonary opacity less than 3cm in diameter Opacities larger than 3cm are termed masses Characters - Size, number - Growth - Calcification - Margins - Central lucencies s Size one number 80% of nodules less than 2cm are benign Multiple nodules are suggestive of metastatic deposits Growth Doubling time between 1-15 months requires further evaluation s Calcifications Calcification usually suggest a benign lesion Calcification patterns include central, laminated, diffuse, popcorn Absence of calcium is of little value in distinguishing benign from malignant lesions Up to 60% of benign nodules and 90% of malignant nodules do not contain calcium s Other densities within the nodule Fat= pulmonary hamartoma - Slowly growing benign lesion - Middle age - 50% contain fat, 30% contain calcium s Cavitations Thin wall < 5mm= benign lesion Thick wall> 15mm= Malignant lesion s Margins Smooth well defined margin= benign nodule ILL- defined or speculated margin= malignant nodule s Other signs Pleural tail may suggest malignancy Satellite nodules surrounding a dominant nodule? Granulomatous Feeding and draining vessels entering the hilar aspect of a nodule = AVM Halo sign [ground glass veiling around the nodule]= lesion with angio invasive character? Aspergillosis

Air crescent sign= intercavitary nodule Air bronchogram= broncho alveolar carcinoma Common lesions Pulmonary nodules Carcinoma Metastases Tuberculomata Fungus Hamartoma AVM Tuberculoma usually single, smooth edge, may Hamartoma 8% usually single, smooth edge, Peripheral bronchogenic carcinoma Solitary peripheral subpleural mass 52% Upper lobe distribution 70% Calcification 1% Spiculated margin due to demoplastic reaction calcify, less than 3cm calcification 15% Popcorn less than 3cm

Metartatic deposits Multiple in 75% variable size Subpleural in 80% Smaller than 2.5cm with smooth edge Deposits are more likely when : Multiple >10 in one patient Non calcified rounded 2-5cm Special types of deposits Fine micronodular pattern? milliary deposits Metastases + pnemothorax (Osteogenic)2% Cannon ball deposits Supportive diagnostic signs or metartatic deposits Mass -Vessel sign[ connection between metastatic nodule and the adjacent branch of the pulmonary artery] Zone of hypodensity distal to nodule=hypoperfusion Reticular changes around the nodule [ neoplastic cells in the vessels and lymphatics] Pulmonary AVM Simple type 80% complex type 20% Lower lobes 70% Bilateral 8-20% Sharply defined lobulated /rounded mass lesion in 90% 1- few cm in size- No calcification Cord like bands from the lesion to hilum Pulmonary lesions Pulmonary masses [more than 3cm] SOLID Carcinoma Metastases

CYSTIC Hydatid cyst Bronchogenic carcinoma Peripheral lesion Mediastinal lymphadenopathy Chest wall invasion Upper abdomen [liver, suprarenal deposits] Bronchogenic carcinoma Central lesion Mediastinal lymphadenopathy Mediastinal invasion - Vascular encasement [SVC, pulmonary, aorta] - bronchial encasement Obstructive changes Upper abdomen [liver, suprarenal deposits] Hydatid cyst Solitary 75% multiple 25% Sharply circumscribed 1-10 cm in diameter Water density Multiple cysts in the wall of a large cyst Calcification rare Rupture ( fluid level (wavy) (water lily sign) Complications - Rupture between the layers of the cyst( (meniscus sign) - Rupture into a bronchus ( air fluid level [water lily sign] - Rupture into pleura ( hydropneumothorax Pulmonary lesions Cavities Wall thickness- fluid level Abscess Bulla Cyst - Pneumatocele - Cystic bronchiectasis Pneumatocele A thin-walled cystic air filled lesion May contain fluid level May reach a large size to fill the hemi thorax Usually follow staph. Pneumonia in children Usually clear spontaneously within 6 weeks Intracavitary lesions Fungal ball Tumor Hydatid Blood clot

Pulmonary lesions Patches [air bronchogram] Pneumonia Infraction Pneumonia 3 basic Radiographic patterns Air Space pneumonia [pneumococcal pneumonia] - Non segmental distribution - Air bronchogram - No volume loss Bronchopneumonia [Staphylococcal infection - Starts in the airways and spreads to alveoli - Bronchial or bronchiolar obstruction ( atclectasis - No air bronchogram Interstitial pneumonia [Viral, mycoplasma infection] - Involves the interstitial septa reticular pattern Extensive infection can cause mixed pattern Pulmonary Infarct Peripheral, wedge shape, pleural base patch Pleural effusion Filling defects in the pulmonary artery Marginal enhancement Diffuse lung disease Reticular pattern Ground glass pattern Nodular pattern Cystic pattern Reticular pattern [ Interlacing linear shadows appearing as a mesh or net] Interstitial lung disease Usual interstitial pneumonia Desquamative interstitial pneumonia Acute interstitial pneumonia Non specific interstitial pneumonia Interstitial pulmonary edema Idiopathic pulmonary fibrosis Collagen vascular diseases Drug induced lung diseases Radiation induced lung diseases Interstitial lung disease HRCT findings Linear densities within the lungs Peribronchial cuffing [bronchial wall thickening] Septal lines [short lines perpendicular to the pleura] Cystic abnormalities and honeycombing [multiple peripheral cysts, mm-cm, thick walls] Traction bronchiectasis

 Other findings Spider appearance of the interlobular vessels due to interstitial opacities around the vessels Thickened interlobar fissures Interface sign [subpleural irregularities ] Subpleural lines curvilinear arc lines parallel to the pleura Ground glass density Sarcoidosis Multi system granulomatous disease Unknown etiology 90% of patients with sarcoidosis have chest changes - Bilateral hilar and mediastinal adopathy - Interstitial disease lymph nodes - Alveolar pattern simulating acute inflammatory disease] - Cavitation, atelectasis, effusion are rare Drug induced lung diseases Immunologic reaction to drugs Interstitial pattern similar to interstitial edema which progresses to alveolar pattern [busulfan, bleomycin, cytoxan,..] Alveolar infiltrates similar to pulmonary edema [penicillin, sulfonamides,..] Pleural and pericardial effusion + basal infilterates [isonaizid,] Hilar adenopathy [antionvulsant,..] Air space filling disease Replacement of alveolar air by fluid, cells, other material Represents an ongoing potentially treatable lesion THREE PRESENTATIONS: Ground glass density [geographic distribution] morphologic changes below the resolution of CT due to Minimal septal thickening Alveolar wall thickening Small amount of fluid in the alveoli Nodules few mm- 1cm Confluent opacities= Frank consolidation with air bronchogram Ground glass pattern [ Increased attenuation of the lung with preservation of bronchovascular marking] - In Patients with AIDS, ground glass opacities= P.carinii pneumonia - In Patients with lung transplant, ground glass opacities= cytomegalovirus pneumonia or rejection - Solitary small area of ground glass opacity= bronchoalveolar edema or bronchoalveolar carcinoma Ground glass pattern Causes Interstitial disease 54% Air space disease 14% Equal interstitial and alveolar involvement 32% Acute lung disease with ground glass opacities Pneumonia Pulmonary edema Pulmonary hemorrhage

Air bronchogram sign Air filled bronchi passing through opaque lung parenchyma confirms that the opacity is intrapulmonary Pneumonia Edema Others Bronchoalveolar carcinoma Lymphoma Infection Alveolar filling disorders Diffuse pulmonary hemorrhage Hemoptysis, anemia and air space opacities Appear rapidly and clear within few days Spare the lung apex and peripheral zones Bilateral, may be asymmetric, air bronchogram Repeated attacks may induce pulmonary fibrosis Diffuse pulmonary hemorrhage Antiglomerular basement membrane disease [Goodpastures disease] Autoimmune disease Circulating antibodies against renal glomerular and pulmonary alveolar basement membranes Young men with respiratory rather than renal manifestations Dyspnea, cough, hemoplasis,10% have hematuria Diffuse pulmonary hemorrhage Immune complex [SLE, Rhumatoid, scleroderma, periarteritis nodosa] Glomerulonephritis Antiglomular basement membrane disease Idiopathic pulmonary hemosidrosis Drug induced [anticoagulants, pnecillamine, amphotericin, mitomycin] Bleeding disorders Alveolar filling disorders Bronchoalveolar carcinoma 6-10% of primary lung cancer Cough, sputum, weight loss, hemoptysis, bronchorrhea Single or multiple pulmonary nodules, segmental or lobar consolidation, diffuse air space disease. CT angiogram sign (non specific) CT angiogram sign [ Visualization of pulmonary vessels within airless lung] Bronchoalveolar carcinoma Others Lymphoma, pulmonary edema, some types of pneumonia [obstructive, lipoid] Alveolar filling disorders Alveolar proteinosis male> female 4:1 Alveolar filling by proteinaceous material Possible causes Idiopathic Occupational (silica) Drug- induced Immune compromise Geographic distribution of areas of ground glass opacities + thickened interlobular septa within ( crazy paving appearance ) Air bronchogram is uncommon

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Nodular pattern [ multiple rounded opacities 1-10mm] Milliary [1-2mm], the size of millet seeds TB metastases fungal pneumoconiosis Miliary TB Hematogenous dissemination Innumerable fine nodules Uniform distribution Mild thickening of the interstitial lung markings Silicosis Inhalation of high concentrations of silicon dioxide Fine interstitial opacities with B Kerleys lines (early) Multiple nodular shadows scattered in the lungs (classic) - Sparing apex and base - Calcification may occur Nodules enlarge and coalesce to form masses [progressive massive fibrosis] - Bilateral, almost symmetrical - Almost always in the upper lobes of the lungs - The more the fibrosis, the less apparent nodules Pulmonary alveolar microlithiasis Innumerable tiny calcific particles are diffusely distributed in the alveoli Most patients are asymptomatic Dense sharply defined nodules The density is greatest in the lung bases Black pleura sign [unaffected pleura between lung and ribs] Coal Workers pneumoconiosis Inhalation of high concentration of coal dust Fine interstitial opacities similar to silicosis Nodules are less defined Progressive massive fibrosis similar to silicosis Cystic pattern [ multiple thin walled air containing lesions measuring 1cm or more ] Histeocytosis Lymphangioleiomyomatosis Lymphocytic interstitial pneumonia Emphysema Cystic bronchiectasis Tuberous sclerosis Pulmonary Histeocytosis X Histeocyte proliferation in the lung Widespread cysts and nodules Nodules are usually> 5mm, solid with irregular margins Cysts are usually > 10mm sparing the lower lung zones The lung volume is preserved Spontaneous pneumothorax 15% of cases Lymphangioleiomyomatosis (Rare) Proliferation of smooth muscles in the walls of bronchi, alveoli, vessels and pleura (air trapping) Seen only in females usually in the reproductive period (30-35Y) Widespread thin walled cysts 2-5 cm in diameter

Cysts involve the whole lung with no nodules Complications Recurrent pneumothorax

Chylous effusion

Emphysema Plain film findings Prominent hilar vascular shadows+ peripheral attenuation of the vascular markings Increased retrosternal and retrocardiac spaces (lateral view) Low flat diaphragm, elongated cardiac shadow Emphysematous bullae?! Emphysema Centrilobular and paraseptal types Lack of a perceptible cyst wall Vessels are seen coursing within the cystic air spaces Typical upper lung subpleural distribution [paraseptal types] Tuberous sclerosis Autosomal dominated disorder male= female Pulmonary changes are seen almost only in females in 3rd -4th decades Changes are similar to lymphangioleiomyomatosis Except chylous effusion which is rare in T. sclerosis Angiomyolipomas of the kidney and liver help in diagnosis Cystic bronchiectasis Cystic structures continuous with the bronchial tree Dilated bronchi imaged longitudinally are helpful in DD [5mm scan interval] Signet ring sign [the ring represents to dilated bronchus, the near-by pulmonary artery= stone] Diseases causing cystic bronchiectasis - Tracheobronchomegaly [The trachea is involved] - Cystic fibrosis [upper lung predominance] Cystic fibrosis Autosomal genetic defect ? abnormal chloride transport across epithelial membranes ? decrease water content of airway mucus ? mucus bluging ? obstructive changes + bronchial wall inflammation ? bronchietasis [typically panlobar] Imaging findings Central bronchiectasis is seen in almost all cases Bronchial wall thickening Peribronchial interstitial opacities Mucus blugging ? branching or nodular opacities Mosaic pattern[ areas of hypertranslucency] [decreased perfusion]

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STAGING OF BRONCHOGNIC CARCINOMA

STAGING OF BRONCHOGNIC CARCINOMA

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Focal Pulmonary parenchymal lesions

Nodules less than 3cm Density Number Margin Calcification

Masses More than 3cm

Patches air bronchogram

Cavities see under cavitary lesions

Pneumonia Infarction Bronchoalveolar carcinoma Pulmonary contusion [history of trauma or rib fracture] See also diffuse lung diseases [air space filling]

Solid Bronchogenic Ca Metastases

Cystic Hydatid

Focal Pulmonary parenchymal lesions Pulmonary nodules less than 3cm

Minute nodules (mm) See diffuse lung disease [Nodular pattern]

1cm up to 3cm in diameter

Number

NB Multiple tuberculomas or hamartomas are rare. Calcified deposits occur in case of osteosarcoma and mucinous adenocarcinoma Multiple spiculated lesions are not considered deposits, but NHL, fungus and sarcoid may be suggested Calcification are seen in bronchogenic carcinoma when develops on top of a granuloma or in larger lesions > 3cm A nodule is considered AVM when connected to the hilum by vascular pedicle. Single Margin Spiculated margin Consider NHL or Fungus Spiculated Bronchogenic Ca Smooth Calcification +ve calcium Tuberculoma Hamartoma AVM -ve calcium Deposits Water density Hydatid Smooth Deposits Multiple

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Diffuse pulmonary parenchymal diseases

Reticular pattern

Ground glass pattern [Increased attenuation of the lung with preserved bronchovascular markings]

[Interlacing linear shadows appearing as a mesh or net]

- Usual interstitial pneumonia - Acute interstitial pneumonia - Non specific interstitial pneumonia - Dequamative interstitial pneumonia - Idiopathic pulmonary fibrosis - Collagen vascular diseases - Drug induced lung diseases - Radiation induced lung disease - Interstitial pulmonary edema

Pneumonia Acute pulmonary edema Pulmonary hemorrhage AIDS + ground glass opacities = P. carinii pneumonia Lung transplant + ground glass opacities = CMV or rejection Solitary ground glass opacity: Bronchoalveolar edema Bronchoalveolar carcinoma

Mediastinal lesions In each mediastinum [cyst, lymph nodes and hernia]

Anterior mediastinum
Cyst Pleuro pericardial cyst at the Rt cardiophrenic angle Nodes Retrosternal, prevascular Circum cardiac = NHL Masses Retrostronal thyroid [continuous the thyroid or removed thyroid + calcification] Teratodermoid cyst [Cystic + calcium + fat densities] Thymic lesions Thymoma, lymphoma,... Lesions with abscent above mentioned criteria Cyst

Middle mediastinum
Bronchogenic cyst Hernia Nodes Hiatus hernia aortic window, hilar carinal, rtetrocaval Masses all are vascular aortic aneurysm [sacular or dissecting] Pulmonary aneurysm Pulmonary embolism Venous thrombosis Cyst

Posterior mediastinum
Neuro entric cyst Nodes Hernia Masses Zygoesophageal Bockdaleck hernia Neurogenic tumours oesophageal lesions - Carcinoma - Achalasia - Lieomyoma Vertebral lesions Potts disease Metastases

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Chest Wall lesions Rib destruction or mass centered to the chest wall or extrathoracic
Lesions with characteristic CT features
- Hypodense lesion with marginal enhancement = abscess - Hypodense lsion measuring fat = lipoma - Lipoma with central soft tissue densities = liposarcoma - Serprgenous enhancing lesion calcified phleboli = hemangioma or AVM - Destructive lesion with matrix calcification Specially of sternum = chondrosarcoma - Lesion or lesions with pulmonary or hepatic deposits = deposits - Large cystic lesion in the axilla = hygroma

Lesions with no specific characters nor associated with other lesions

Usually Solid

Usually deposits

Biopsy

Rare lesions
Myloma Hematoma

Invasion by an intrathoracic Pathology - Bronchogenic carcinoma - Msothelioma

Lymphoma

Diffuse pulmonary parenchymal diseases

Nodular pattern
(Multiple rounded opacities - 1-10 mm)

Cystic pattern
(Multiple thin walled air containing lesions) 1 cm or more in diameter
Histeocytosis

Random distribution TB Fungal Deposits Zonal

pneumoconiosis

Special distribution

Lymphangiolieomymatosis Lymphocytic intersitial pneumonia Pneumocystis carinii pneumonia

Perilymphatic
Sarcoid

Bronchovascular
Lympoma Leukemia

Centrilobular emphysema

Cavitating nodules
Deposits Wegeners granulomas Septic emboli Rhumatoid lung

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Focal Pulmonary lesions Cavitary lesions

Contents

Air fluid leel Air only

Intracavitary soft
tissue density

Surface of the fluid level

Thick Straight Abscess ruptured hydatid cyst Wavy Chronic abscess

Wall thickness

Fungal ball (most common) Rupture hydatid cyst Thin Breakdown in a tumour Blood clot

Site Central in the lung Pneumonia Peripheral subpleural emphysematous bulla

Mediastinal nodes
Single or few nodes
Metastatic [known primary or primary in the chest e.g bronchogenic Ca.] Inflammatory nodes [rare] - Draining a T. B focus [1ry complex] - Draining infection in the chest wall or mediastinum Lymphoma affection of circmcardiac nodes = NHL

Multiple nodes

Discreat nodes

Bulky amulgamated masses

Bilateral symmetrical

Asymmetrical nodes

With lung infiltrates - Sarcoidosis - Some pneumoconiosis

Clear lungs lymphoma Sarcoid (nodal type)

With lung infiltrates - Lymphangitis Carcinomatosa

Clear lungs deposits or lymphoma

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Virtual Bronchoscopy
By Naglaa Abdel Razek,MD Since the introduction of computed thoracic tomography (CT), the implications of this imaging modality for the evaluation of patients with diverse respiratory diseases have been obvious. The particular relevance of chest CT to the diagnosis, staging, and therapy of patients with lung cancer has been readily apparent, and CT has become an established component of their noninvasive evaluation. Increasing use of volumeteric scanning with the recent introduction of spiral and multislice CT scanners has led to the rapid acquisition of cross-sectional imaging data encompassing the entire thorax and the manipulation of this information using innovative computer technology have led to multiplanar and three dimensional (3D) reconstructions as well as improved conventional cross-sectional images . Virtual bronchoscopy is a type of three-dimensional reconstruction in which the observation point is placed within the airway to produce endoscopic like display without the use of endoscope Use of increasing computer power has facilitated rendering such images in real-time (15 to 30 frames/second), thus mimicking the view obtained as a fiberoptic bronchoscope courses through the tracheobronchial tree (Haponik et al., 1999).

Steps for Creating Virtual Bronchoscopy The basic steps for creating virtual bronchoscopy include: - Image acquisition. - Image processing: Segmentation Fly through (creation of virtual reality) - Image analysis. - Image display 1.Image Acquisition : The recent development of slip ring technology, spiral (helical) CT scanners allows continuous data acquisition while the patient is moved through the scanner. A large portion of the patient can be scanned during a single breath hold, yielding a volume of data without confounding motion artifacts. The length of the scan volume is affected by several factors. These include table speed, slice collimation, x-ray tube capacity and duration of breath holding. These factors also influence the quality of the acquired images. Maximum resolution during virtual bronchoscopy was obtained with the smallest beam collimation, slowest table speed and maximum degree of reconstruction slice overlap. It was noted that slice thickness was the single most important factor for revealing fine structures, overlapping sections of 2mm provided the best overall results.

Virtual bronchoscopy images with external 3D reconstruction showing a short segment of bronchial narrowing (arrowed)

2.Image Processing Much of the computing task has now been transferred to independent workstations. The recent development of the digital Imaging and Communication in Medicine (DICOM) format and use of internet connections allow rapid transfer of data between scanners and workstations. The Segmentation

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BY definition segmentation is the method by which the user can generate a stereoscopic images of the inner walls of any cavitary organ from original axial images, similar to those visualized using an endoscope. Thresholding The earliest attempts at the application of three-dimensional imaging in the chest used simple thresholding to produce an external view of the lungs and tracheobronchial tree (Newmark et al., 1994). In thresholding, volume elements (voxels) were included if the attenuation value was below a selected Housenfield level and excluded if above this level. More sophisticated segmentation methods were being developed which use advanced image processing techniques that allowed reconstruction of all connected voxels within the airway lumen with threshold that were within a specific range. Fly Through-Navigation The results of region extraction (segmentation) was a three-dimensional representation of the tracheobronchial tree. Users can navigate freely through the computer-generated anatomy by controlling their direction of flight with a mouse cursor and their speed (Forward and backward) by pressing mouse buttons. A retroflexed view from within simulated bronchi may allow the user to look towards the trachea. 3.Image display: Optional approaches to viewing the images generated have included the review of computer monitor, scans, or still photographs of airway abnormalities and common endobronchial regions of interest, video presentations of the simulated airway examination. 4.Image analysis: The images are interpreted for : Endobronchial lesion. Extraluminal compression. Bronchial narrowing or bronchial stenosis. The status of the bronchial tree distal to a stenosed or obstructed segment.

Tracheobronchial Anatomy To appreciate normal tracheobronchial anatomy and pathology on simulated endoscopic images, it is important to familiarize oneself with appearance of normal tracheobronchial anatomy on conventional bronchoscopy.

Potential Applications of Virtual Bronchoscopy: Virtual bronchoscopy has the potential to influence the appraisal of all levels of the respiratory tract from the upper airway to the lung periphery. Numerous educational, diagnostic, and interventional roles for virtual bronchoscopy might be envisioned. 1.Upper Airway Diagnosis One application of this new perspective has been in the evaluation and management of patients with upper airway and tracheal disease 2.Lower Airway Diagnosis Preliminary experience with virtual bronchoscopy has focused on the feasibility of detecting major, central lower airway abnormalities, particularly in patients with neoplastic disease. VB was superior to FOB in detecting endoluminal masses located in peripheral bronchi beyond the bronchoscopist field of direct vision. Or in detecting lesions distal to a proximal stenosed segment. It was found that, the combination of endobronchial and extrabronchial 3-D reconstructions was helpful in characterizing bronchiectasis, effectively providing a bronchogram-quality image.

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3.Staging There are several foreseeable applications of virtual bronchoscopy in the staging of patients with lung cancer. The added informations by VB, regarding the relation of the tumor to the tracheobrnochial tree, combined with the conventional CT criteria of tumour staging had led to transfer of of patients with Bronchogenic Carcinoma to higher grades of malignancy. The effects of virtual bronchoscopy on bronchoscopic sampling of mediastinal lymph nodes by means of transbronchial needle aspiration (TBNA). The capability of rendering simulated airway walls semitransparent to reveal extrabronchial structures from a perspective within the airway is especially relevant to TBNA. 4.Interventional Roles Increasing experience with laser photocoagulation procedures, brachytherapy, endobronchial cryotherapy, and placement of trachobronchial stents has affirmed the importance of accurate preoperative characterization of airway abnormalities and postoperative assessment of treatment. Measurements of stenoses, optimize stent fitting and implantation 5.Application in Paediatrics Likewise the indication for flexible bronchoscopy is, especially in very young children, restricted. Not only is it an invasive procedure, but also the inevitable sedation along with its risks need to be considered. In these instances virtual bronchoscopy may be calculated after high quality CT study. The indications for virtual endoscopy included suspected aberrant bronchus, recurrent infiltrates, tracheal stenosis, middle lobe syndrome, etc. 6.Educational and Research Applications The graphic renderings of anatomy for medical education. Bronchoscopy training and prebronchoscopy planning. Preparations for a current patient's procedure. Contributions to communications in the medical literature. Limitations of Virtual bronchoscopy are: 1. It is a static examination technique; it is not as sensitive as true endoscopy in detecting the cause of airway obstruction that was based on dynamic movement. 2. 3D CT and VB software relies on the presence of air. Mucous plugs or secretions inside the lumen can make an airway appear suspiciously stenosed. 3. It provides no color or texture of the airway mucosa because this is not represented in the CT data. Advantages of Virtual Bronchoscopy: 1. It is non invasive. Thus it is indicated when the flexible bronchoscopy can't be performed.

2. Stenosis, obstructions or endoscopically inaccessible areas are no obstacles for it. 3. Extra luminal information is always available and provides guidance for ensuring interventions. 4. Through distortion-free presentation modes (MPR, mIP, etc) exact measurements can be achieved 5. It can be performed under mild sedation. 6. It can improve conventional Endoscopy techniques by providing orientation relative to the patient or relative to the immediate surrounding anatomy. 7. It provides more information to help design accurate stents than bronchoscopy. Conclusion: No generalized statements can be offered because the individual methods and their disadvantages must be considered in light of the clinical situation. Flexible bronchoscopy in the hands of an experienced pulmonologist will remain the gold standard in the near future. However, along with rapid advantages in computing speed and the future expansion of multislice CT technology, virtual bronchoscopy will find its place in the daily routine and will continue to exist as one of many presentation forms to chose from for chest imaging .

Thank you, Naglaa Abdel Razek,MD Lecturer of Radiology. Cairo Universiy

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