DIFERENSIAL DIAGNOSIS

BAYANGAN RADIO OPAQUE NODULER

Oleh:
Viana Villamanda Jatnika (12100114085)
Preceptor:
Dyana Eka Hadiati dr., Sp.Rad
Fakultas Kedokteran UNISBA
RSUD AL IHSAN BANDUNG
2015

1. Soliter
a. Small (d: 0,5-3 cm coin lesion)
Malignancy primer atau sekunder
Adenoma
Hamartoma
Granuloma
Exudat
Arteri-Venous aneurysma
b. Large (d: >3 cm)
- Berbatas tegas
Kista dengan cairan penuh
Tumor-tumor dari pleura
- Berbatas tidak tegas dan tidak teratur
Abses, granuloma
Infark

KLASIFIKASI

2. Multiple
Multiple pulmonary metastasis tumor
Pneumoconiosis
Caplans syndrome (Rheumatoid pneumoconiosis)
Silo-fillers disease

3. Granular (miliar) d: < 0,5 cm

Miliary TB
Histoplasmosis
Sarcoidosis
Pulmonary Amyloidosis
Alveolar Ca. dari paru
Metastase

KLASIFIKASI (2)

Large Nodule

Granular Nodule

A.

Large nodular

1. Abses Paru
Supurasi dan nekrosis jaringan paru-paru
Etiologi:

Tuberkulosis
Staphylococcal & Klebsiella pneumonia
Infeksi fungi
Tumor malignan
Infected cyst

SOLITER NODULAR

Kebanyakan

berjumlah 1
Homogenous opak
Terdapat lesi pneumonic disekelilingnya
Round cavity, distinct border with wall consist of
granulation tissue
Biasanya terdapat pada segmen posterior lobus
superior (kanan>kiri)
Biasanya subpleura dan dapat ruptur menuju
pleura, menyebabkan fistula bronkopleural
air-fluid level (+)

DD Lung Abscess :
1. Cavernae TBC
Mostly in apex/subapical
Irregular cavity, distinct border with TBC
lesion around them

2. Cavity in malignancy (bronchogenic

ca)
Thick wall, irregular/shaggy border
Tumefaction in cavity
Satellite metastatic nodes

3. Pulmonary cyst
- Thin walled
- Solitary/multiple
- Sometimes accompanied by emphysema

4. Mycotic processes cavitation

- Thin walled with fungus ball inside
- Positional change fungus ball changed
- Sometimes with fistula

A large Aspergillus
mycetoma (fungus ball)
within a cavity

2. Carcinoma Paru
a. Bronchogenic Ca
- sering
- pria > wanita
- kanan > kiri
- Usia: 50 60 thn
- FR : merokok, radioaktif/material industri, TBC
- gambaran radiologi: massa di paru sebsear
4-12 cm, bentuk bulat atau oval yang
berbenjol (lobulated)
b. Pancoasts tumor

Posterior superior pulmonary sulcus tumor

Posterior costae 1- 3 destruction with

vertebral erosion

Cervicalis symphatis paralysis Horner

syndrome

BRONCHOGENIC CA

PANCOAST TUMOR

3. Alveolar cell ca (Pulmonary adenomatosis)

Pria=wanita
40 tahun
Radiologi:
Nodul kecil pada kedua paru-paru
dipenuhi
dengan massa besar pada base paru-paru kanan
Tidak terlihat pembesaran node namun terlihat
konsolidasi node di perihiler
Pleura biasanya tidak terpengaruhi
Jantung normal

Alveolar cell ca (Pulmonary adenomatosis)

4. Hamartoma
Pertumbuhan berlebih beberapa jaringan seperti
smooth muscle fibrous cartilage tissue and vascular
Radiologi :
Tumor bulat atau bergelombang (lobulated)
dengan batas tegas
Ukuran <4 cm
Calsification inside : pop corn calcification

HAMARTOMA

Large multiple nodular disorder

1. Multipel metastasis tumor
dari organ yang berdekatan:
- Oesophagus
- Thyroid
- Mammae

Multiple Nodular

2. Pneumoconiosis
Occupational disease
Penyakit paru-paru akibat menginhalai
substansi asing
Lung reaction if invaded by foreign substance
Fibrosis : Silicate
No reaction : Siderosis
Pneumonitis & fibrosis : Beryllium, Mangan, Gas
Fibrosis / allergy : Cotton linen
Carcinogen : Radioactive, Asbestosis, Arsenic

3. Silikosis
tahun

gejala muncul setelah 3

Radiologi :
Gambaran fibrotik tipis sekitar
bronkovaskular
Proses lanjut: gambaran noduler pada kedua
lapang paru
Kelenjar hilus membesar dengan kalsifikasi
tipis, dikenal sebagai gambaran kulit telur

SILIKOSIS

Late stage of silicosis

The chest x-ray (A) shows significant parenchymal disease, predominant in the upper lobes, as
a result of progressive massive fibrosis. The regular (B) and high-resolution (C)
computedomography scans show both coarse interstitial and nodular changes.

4. Asbetosis
-penebalan pleura disertai fibrosis paru
-Pada lapangan paru bawah, terutama paru
kiri sekitar parakardial yang menutupi jantung
kiri
-Kadang teradpat pembesaran hilus

ASBESTOSIS

5. Siderosis
- Deposisi endapan debu besi
Bayangan noduler dengan densitas lebih tinggi
disertai jaringan fibrotik
Tidak mempunyai batas tegas
Tidak ada pembesaran hilus

6. Berrylosis
Stadium akut: pneumonitis kimiawi dengan
gambaran edema dan perdarahan berupa
bayangan suram paru dengan pembesaran
hilus
Stadium kronik: granuler atau noduler fibrotik
yang mencapai ukuran 1 cm
- stadium lanjut: garis fibrotik atau ateletaksis

SIDEROSIS - BERRYLOSIS

Depending on position:
Apex : Pulmonary TBC
Undefined:
TBC
Mycosis
Bronchopneumonia

Basis
Bronchiectasis + Secondary infection
Hypostatic pneumonia
Aspiration pneumonia

In 2/3 lung medially

Pulmonary oedema & uremic lung

Small Nodule

TBC

The classic appearance of reactivation tuberculosis is that of an upper lobe infiltrate with cavities (A). Over time,
healing and fibrosis will occur, which will pull the hilum up on the affected side. If any question remains about
whether the infiltrate is cavitated, a computed tomography scan (B) may be useful.

MYCOSIS

Fungal infections of the lung may initially be seen as an alveolar infiltrate (A), but several days later (B), they
may show cavitation (arrows), with a central loose mass representing a fungus ball.

Bronchopneumonia
Small nodular, poorly defined,
irregular confluent
In middle and basis (ussually)

31

BRONCHIECTASIS

A posteroanterior chest x-ray in a patient with bronchiectasis demonstrates bronchial wall thickening, most
pronounced at the lung bases(A). This is often referred to as tram tracking or linear parallel lines that
represent thickened bronchial walls (arrows). In advanced bronchiectasis (B), coarse basilar
lung infiltrates may appear cavitary. Bronchiectasis is much better seen on a computed tomography scan (C)
than on a chest x-ray. The findings are of dilated bronchiwith thickened bronchial walls (arrow).

A chest x-ray obtained immediately after aspiration may be quite normal (A). The chemical
pneumonia takes 6 or 12 hours (B) to cause an alveolar infiltrate (arrow).

Pulmonary oedema
Infusion overload
Renal failure oedema
Heart failure oedema
CNS disease : cerebral tumor / post op
Collagen disease
Rheumatoid arthritis
Periarthritis nodosa
Scleroderma
Gas / fluid inhalation
Radiologi :
Smooth / small noduler in medial
Ussualy >> cor

34

Milliary TBC
Milliary carcinoma
Pneumoconiosis
Bronchiolitis
Alveolar cell Ca
Sarcoidosis
Milliary mycosis
Pulmonary amyloidosis
Bronchiectasy with secondary infection
Interstitial bronchopneumonia
Rheumatic bronchopneumonia
Pulmonary congestion

GRANULAR NODULAR

Milliary TBC

Milliary carcinoma
(Papillary thyroid carcinoma with miliary metastases)

Pulmonary cyst
Spherical cavity, thin walled, non-granulomatous, filled
with air / fluid.
Klasifikasi :
A. Solitary
Congenital cyst
Infection cyst
Neoplastic cyst
B. Multiple
Apex:
Bleb
Bulla
Basal

Bronchiectasis cyst
Pneumatocele cyst
38

Hydatid cyst / echinococcus

Pada zona tengah dan bawah
Jarang terjadi kalsifikasi
Size: 1-10 cm
Unruptured cyst:
One/more homogeneous, bulat/oval,
massa intrapulmonal berbatas jelas
Ruptured cyst:
A complex ring shadow with two walls

Infection Cyst

INFECTION CYST

Congenital cyst
Origin
Embryonal primary lobe
Endoderm disorder mucosa like gaster
Connected / not connected with digestive tract
Solitary thin walled with fluid
Connected with bronchus air fluid level

CONGENITAL CYST

Bleb & Bulla

Bulla :
Vesicular
emphysema area in
lung tissue
> 1 cm
Bleb :
Interstitial
emphysema that
located between
visceral pleura and
lung tissue

Bilateral
bullae
44

Giant Bulla
Solitary, unilateral asym. lung
Bulla will pushes mediastinum & diaphragma
DD: Pneumothorax
If very large pneumothorax

45

Berdinding tipis, merupakan kista yang berisi

udara yang berkembang di dalam parenkim
paru
Biasa terjadi karena sequele pneumonia akut
yang disebabkan oleh staphylococcus aureus

Pneumatocele

PNEUMATOCELE

TERIMA KASIH