DIFFERENSIAL DIAGNOSIS

BAYANGAN RADIO OPAQUE

NODULER
Dimas Harendra 12100110014
Preceptor: dr. Dyana., Sp.Rad
Fakultas Kedokteran UNISBA

Klasifikasi
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

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

Large Nodule

Granular Nodule

Soliter nodular
A. Large nodular
1. Abses Paru
Supurasi dan nekrosis jaringan paru-paru
Etiologi:

- Tuberkulosis
- Staphylococcal & Klebsiella pneumonia
- Infeksi fungi
- Tumor malignan
- Infected cyst

 Mostly single
Homogenous opak
Pneumonic lesion in surround
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
Sometimes with 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

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

Multiple Nodular
Large multiple nodular disorder
1.Multipel metastasis tumor
dari organ yang berdekatan:
- Oesophagus
- Thyroid
- Mammae

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

Silikosis gejala muncul setelah 3 tahun

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

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

Siderosis
-

Deposisi endapan debu besi

- bayangan noduler dengan densitas lebih tinggi disertai

jaringan fibrotik
- Tidak mempunyai batas tegas
- Tidak ada pembesaran hilus

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

Small Nodule
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

Bronchopneumonia

Small nodular, poorly defined,

irregular confluent
In middle and basis (ussually)

22

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

23

GRANULAR NODULAR

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

Milliary TBC

Milliary carcinoma
(Papillary thyroid carcinoma with miliary metastases)

Alveolar cell Ca

Sarcoidosis

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

Radiologi:
Spherical cavity in all projection except in near diaphragm or chest wall.
If filled full with air radio opaque
If Ruptured to bronchus air fluid level
If infected thick walled, loss of sharp defined
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Infection Cyst
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

Congenital 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

Bleb & Bulla

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

Bilateral
bullae
32

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

33

Pneumatocele
- thin-walled, air-filled cysts that develop within the lung
parenchyma
- Most often, they occur as a sequela to acute
pneumonia, commonly caused by S. Aureus
- Observed soon after the development of pneumonia but
can be observed on the initial chest radiograph.

TERIMA KASIH